HIV in Indian prisons : Risk behaviour , prevalence , prevention & treatment

living with HIV. India accounts for about half of these infections1. Sentinel surveillance conducted by the National AIDS Control Organization (NACO) shows that in the general population HIV prevalence is low (0.25-0.43%), but among high-risk groups, HIV prevalence is much more. In at least five States, HIV prevalence among injecting drug users (IDU) is greater HIV in Indian prisons: Risk behaviour, prevalence, prevention & treatment

for prison authorities 4,5 because substance use disorders 6 and injecting drug use 7 are common among incarcerated populations.Subsequently, HIV, viral hepatitis and tuberculosis are more prevalent in prison populations than in the general population 8 .
There are an estimated 165,000 IDU in India 9 , and it is common for people who use illicit drugs to experience periods in custody 10 .However, there are very limited data on the prevalence of drug use or other HIV risk behaviours among Indian prisoners.In a study conducted in 1997-2000, around 8 per cent of individuals admitted to Tihar Jail in Delhi were known to be drug users 11 , while in a more recent study of 466 inmates in Delhi, Mumbai and Punjab, 63 per cent reported ever using illicit drugs 12 .Despite this uncertainty, it is highly likely that, as in most countries around the world 7 , people at high risk of HIV infection are over-represented in Indian prisons.
Prisons do not exist in isolation from the community.The majority of prisoners return to the cities and towns they came from.Resumption of risk behaviours such as unprotected sex 13 and drug abuse 14,15 shortly after release from prison is common.This study was carried out to collect information on HIV risk, prevalence, prevention and treatment programme in prisons in India.

Material & Methods
Relevant published material was searched from 1993 to 2010 and unpublished information from key experts relating to HIV in prisons in India was obtained by request.Specific information included three main areas: (i) Rates of imprisonment; (ii) HIV testing, prevalence and risk behaviours; and (iii) HIV prevention, care and treatment.Where gaps in the data remained, key experts were contacted via e-mail or telephone and requests for specific information were made.Key experts included international agencies, non government organizations (NGOs) working in prisons and/or the community in target countries and officials from relevant government ministries and prison administrative bodies.

Results & Discussion
Prison population: The latest figures available on Indian prison population were 376,396 adult prisoners for 2007 16 , making for an imprisonment rate of 32 per 100,000 of national population 17 .
Around two-thirds of inmates were pre-trial detainees 17 .A high proportion of pre-trial detainees means a very large inmate turnover.For example, in Tihar Jail, New Delhi, about 12,000 inmates were held while about 60,000 prisoners were admitted and a similar number were discharged annually 17 .Indian prisons were overcrowded.Across all correctional facilities, the average occupancy level was 136 per cent 16 .The three areas with the largest overcrowding were Uttar Pradesh (201%) followed by Chhattisgarh (193%) and Delhi (185%).

HIV risk behaviours:
No prevalence data regarding drug use in Indian prisons were identified.Two sources identified denial of the possibility of drug use in prisons as an impediment to addressing HIV in prisons 12,18 .
Sex between inmates was reportedly common, at least in one prison 19 .In a study conducted in Arthur Road Jail, Mumbai, 72 per cent of a sample of 752 (75 employees and 677 inmates) said that they thought sex between men was common in prisons and 11 per cent engaged in homosexual activity in prison 20 .
No evidence was found on the prevalence of tattooing in prisons in India.There were reports from Mumbai of interpersonal violence (involving lacerations, bites and bleeding in two or more participants), which could present risks of HIV transmission 19 .
HIV prevalence: No recent HIV prevalence data were identified; existing data were from the mid-tolate 1990s.One national study of HIV prevalence in prisons found that 1.7 per cent of male and 9.5 per cent of female inmates were HIV positive 21 .In other studies HIV prevalence in individual prisons ranged from 0.5 to 6.9 per cent (Table ).Eighteen of 27 inmates who died at Arthur Road Jail, Mumbai, in a six month period were HIV positive 29 .No information on HIV transmission in Indian prisons was found.
HIV prevention: Education: HIV education programmes tended to be ad-hoc and relied on NGOs for facilitation.A sexual health programme, Partnership for Sexual Health, was conducted in 2000 in 11 jails in Andhra Pradesh.Three staff members provided HIV education, counselling, referral and medical treatment 30 .The Mumbai District AIDS Control Society and the International Labour Organisation have conducted a workplace HIV prevention programme at the Arthur Road Jail 20 .In West Bengal, the Vivekananda International Health Centre has delivered an HIV education programme in 20 prisons reaching 50,000 prisoners and staff 26 .In Gujarat, an HIV information and education programme was conducted by NGOs 31 .

HIV prevention: Drug dependency treatment:
Many prisoners who were placed in drug treatment programmes, were on remand and, therefore, often released before completing treatment 32 .Drug offenders received at Tihar Jail, New Delhi were admitted to a de-addiction centre for detoxification and treatment of withdrawal symptoms.A psychiatrist worked with prisoners for approximately one week 33 .In 2005, there were three detoxification centres with 72 detoxification beds: 60 for adult males and 12 for adolescents.
After detoxification, drug offenders were segregated and placed in a therapeutic community run by NGOs.As many as 800 prisoners live within the therapeutic communities at Tihar 32,33 , where prisoners served as team leaders and supervisors.Staff members such as psychiatrists, psychologists, sociologists and social workers, served as trainers, facilitators and counsellors.Inmates were engaged in counselling, education, meditation, family therapy, anger and grief workshops and recreational activities 32,33 .Tihar Jail hosts the only opioid substitution treatment programme in an Indian prison 34 .The programme commenced in 2008; no data on the number of prisoners receiving treatment were reported.

HIV prevention: Harm reduction programmes:
A government run prison intervention in Andhra Pradesh included condom distribution 35 , but this was stopped as being against prison policy 18 .No information regarding bleach distribution was identified and there were no prison based needle and syringe programmes in India 18,36 .
HIV care and treatment: Only one source provided information about access to antiretroviral treatment (ART) while in prison.A programme providing legal aid to prisoners had assisted some HIV positive inmates to continue ART while in prison 18 .
The present findings revealed that only a few HIV prevention, care and treatment interventions have been implemented in prisons in India.Although no data were located on drug injecting in prison, internationally, injecting drug use is a transmission route for HIV inside prisons [37][38][39][40] .Two studies reported that sexual activity occurred in prisons.Unprotected sex is an HIV transmission route in prisons 41,42 and the high levels of overcrowding and lack of access to condoms in Indian prisons may be conducive to unprotected sex.Distribution of condoms has previously been disallowed due to legislation against sex between men 43 ; however, this law was overturned in July 2009 44 .The provision of condoms in prison has been found to be feasible and is not associated with increases in sexual behaviour 45,46 .Some limited, sporadic HIV prevalence data were available, but such data become obsolete rapidly.Regular, nation-wide or State-based collection of Limited HIV prevention programmes were available in Indian prisons.HIV information, education and communication programmes such as those in prisons in Mumbai, Andhra Pradesh should be expanded to all prisons across the country.Improving access to drug dependency treatment, including scaling-up of opioid substitution treatment, would be another positive step 48 .Harm reduction strategies, including condom distribution programmes and needle and syringe programmes, will further assist in reducing the risk of HIV transmission in prison.Several developing countries have introduced methadone maintenance in prison.These countries include Indonesia, Iran and Moldova 48 .
Treatment of HIV and STI is also important in stemming HIV in prisons.Voluntary counselling and testing should be promoted and access to HIV and STI treatment improved.
UNODC recommended that the Government of India initiate a process of inquiry in major prisons in India, and where necessary, set up the required facilities for the treatment of drug users 32 .Large numbers of prisoners under trial pass through India's prisons each year.Legal reforms to increase non-custodial options for monitoring offenders who have been charged but not yet tried are strongly recommended.

Table .
Information on HIV prevalence in Indian prisons